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Biomedical subjects

N S Jecker

Publications and source records attributed to N S Jecker.

At least 37 records · Page 2Linked to original sources
PubMed1994

Beyond futility to an ethic of care.

The medical futility debate is usually framed as a conflict between physician and patient (or surrogate) over the right to decide whether a particular life-saving treatment is futile and should not be attempted. Arguments on behalf of physician-determined futility emphasize the limits of physicians' obligations; arguments on behalf of patient-determined futility reflect concerns over the potential erosion of recent gains in patient autonomy against medical paternalism. Underlying the arguments of those pressing for "value-free" definitions of medical futility and unlimited obligations of physicians to patients may be fears of covert rationing and patient abandonment. Often overlooked in this debate, both at the bedside and in public commentary, is the ethical duty of the physician to redirect efforts from life-saving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family. To supplement the limited terms of the futility debate with an ethic of care, physicians should lead in advocating greater awareness of the ethics of care in doctor-nurse interactions, institutional facilities, insurance policies, and public education.

Ethical Theory↗
PubMed1994

Is dying young worse than dying old?

In contemporary Western society, people experience the deaths of older and younger persons differently. We are disposed to feel that the death of a small child is a greater injustice than the death of an older adult, and we experience correspondingly greater sorrow, anger, regret or bitterness when a very young person dies. This article examines these responses critically to determine whether they are backed by ethical considerations that reason can discern and defend. We contrast contemporary attitudes with those of ancient Greece and show the relevance that different attitudes toward death have for health care decision making.

Age Factors↗
PubMed1994

Managed competition and managed care. What are the ethical issues?

Managed competition and managed care, two hallmarks of President Clinton's health care reform proposal, would significantly change the way that health care in the United States is structured and delivered. This article presents ethical debates about managed care in historical perspective, reviews ethical arguments for and against managed care systems, and concludes with a set of practical guidelines to govern existing managed care arrangements. Throughout the paper, special attention is devoted to the impact of managed care on the elderly population and on physician-patient relationships.

Aged↗
PubMed1993

Privacy beliefs and the violent family. Extending the ethical argument for physician intervention.

Privacy beliefs associated with the family impede physicians' response to domestic violence. As a private sphere, the family is regarded as sacred, separate, and hidden from public view. Hence, physicians who look for or uncover violence in the family risk defilling a sacred object and violating norms of non-interference. Privacy beliefs also obfuscate the ethical analysis of physicians' duties to intercede on behalf of battered patients. Ethical principles of beneficence and nonmaleficence have been invoked to justify physicians' duties to abused patients; however, the principle of justice has not been invoked. Ethical analysis of physicians' duties in this area must be broadened to include the principle of justice. Justice is at stake because establishing conditions favorable to self-respect is a requirement of justice, and the response physicians make to battered patients carries important ramifications for supporting patients' self-respect and dignity. If justice forms part of the ethical foundation for physician intervention in domestic violence, mandatory steps that do not transgress the confidentiality of the physician-patient relationship or infringe the patient's autonomy should be taken, such as requiring domestic violence training in medical education and following treatment plans and protocols to identify abuse and provide assistance to battered patients.

American Medical Association↗
PubMed1993

The influence of philosophical versus theological education on the moral development of clinical medical ethicists.

PURPOSE: Because of the increasing involvement of clinical medical ethicists in patient care and the resultant controversy over the appropriate background, training, and certification of clinical ethicists, this study was designed to investigate whether different educational backgrounds (philosophical versus theological) affected the moral reasoning of clinical ethicists and their orientations toward justice or care. METHOD: From 1987 through 1990, extensive oral interviews were conducted with 50 clinical medical ethicists (26 philosophers and 24 theologians) who were at 32 medical centers in 14 states from all sections of the United States. The interviews were used to gather selected demographic characteristics about the ethicists (age, gender, and educational background) as well as to determine the ethicists' scores for stages of moral reasoning and for moral orientation. Polyserial correlations and multivariant analyses were then performed between the demographic characteristics and the data on moral reasoning and moral orientation. RESULTS: The philosophers and theologians were found not to be significantly different (p > .05) in their moral reasoning skills in terms of either moral stage score or weighted average score. Similarly, the philosophers and theologians were found not to be significantly different in their moral orientations toward justice or care in terms of recognition, predominance, or alignment. No significant relationship was found between age or gender and moral reasoning or moral orientation. CONCLUSION: Based on the results of this study, it appears that clinical medical ethicists, whether philosophers or theologians, are a fairly homogeneous group with regard to their moral development, in terms of both their stages of moral reasoning and their moral orientations toward justice and care.

Adult↗
PubMed1993

A comparison of the moral reasoning of physicians and clinical medical ethicists.

BACKGROUND: Because of the increasing controversy over who should provide ethics consultations, this study investigated differences in the moral reasoning and moral orientations of physicians and clinical ethicists. METHOD: From 1987 through 1990, extensive interviews were conducted with 39 physicians and 50 clinical medical ethicists (26 philosophers and 24 theologians) who were at 32 medical centers in 14 states from all sections of the United States. The interviews were used to gather selected demographic characteristics (age, gender, and profession--physician or ethicist) for the 89 individuals as well as to determine their scores for moral reasoning and moral orientation. Polyserial correlations and multivariant analyses were then performed between the demographic characteristics and the data on moral reasoning and moral orientation. RESULTS: The physicians consistently scored lower than the clinical ethicists in their moral reasoning skills in terms of both moral stage score (p < .01) and weighted average score (p < .01). However, the physicians were found not to be significantly different (p < .05) from the clinical ethicists in their moral orientations toward justice or care in terms of recognition, predominance, or alignment. No significant relationship was found between age and moral orientation. A significant relationship was found between age and stage of moral reasoning, with the older individuals scoring higher. No significant relationship was found between gender and stage of moral reasoning. A significant relationship was found between gender and moral orientation: the women were more likely to recognize elements of care in moral dilemmas and the men more likely to recognize elements of justice. CONCLUSION: This study provides initial evidence that clinical medical ethicists, whether philosophers or theologians, may be better skilled than physicians to do ethicists consultations. To the extent that higher levels of moral reasoning correlate with superior skills in performing clinical ethics consultations, this study shows the value of bringing philosophers and theologians into the clinical setting.

Adult↗
PubMed1993

Can an employer-based health insurance system be just?

It is America's distinctive practice to tie private health insurance to employment, and recent proposals have tried to retain this link through mandating that all employers provide health insurance to their employees. My primary approach to these issues is neither economic, nor historical, nor political but ethical. After a brief historical overview, I outline a general approach to evaluating the ethical significance of linking the distributions of distinct goods. I examine whether an unjust distribution of jobs spoils justice in the distribution of health insurance, taking as a central example gender inequities in employment and exploring their impact on job-based health insurance. Second, I explore the possibility that justly awarding jobs guarantees justice in employment-sponsored insurance. However, linking the distributions of different goods remains problematic, because such links inevitably undermine equality by enabling the same individuals to enjoy advantages in many different distributive areas. Finally, I examine recent proposals to reform America's health care system by requiring all employers to provide health insurance to their employees. I argue that such proposals lend themselves to the same ethical problems that the current system does and urge greater attention to alternative reform options.

Employer Health Costs↗
PubMed1992

Futility and rationing.

It seems more than coincidental that at a time of great concern over rising health care costs and fears of rampant technology, debates are suddenly taking place about medical futility and health care rationing. This article examines the economic, historical, and demographic factors that have motivated increased attention to both these concepts, explores differences and similarities in the meaning of these terms, and discusses their ethical implications. Specifically, we identify four common sources of current debates on futility and rationing: the rise in health care costs; the development of high-technology medicine; the aging of society; and the effort to limit the scope of patient autonomy. We propose that when rationing criteria refer to medical benefit, the meanings of futility and rationing share certain common features. Futility and rationing differ, however, in important ways. Futility refers to treatment and outcome relationships not in a general population but in a specific patient. Rationing criteria usually are supported by reference to theories of justice, whereas the definition of futility, if achieved, will probably be arrived at by empirical community agreement. Rationing always occurs against a backdrop of resource scarcity, but futility need not. Toward the end of the paper, we clarify how the various connotations and contexts we associate with each term enhance or frustrate ethical debate.

Aged↗
PubMed1992

Allocating medical resources in rural America: alternative perceptions of justice.

In national debates concerning the allocation of medical resources rural America is a neglected topic, and the voices of rural health professionals are seldom heard. This paper highlights the special problems encountered in allocating medical resources within the rural setting and indicates the strategies that rural residents compose for dealing with them. Our findings are based on a study consisting of in-depth open-ended interviews with family physicians in the rural northwest United States. We contrast the approach to justice expressed by these rural physicians with the conception of justice that dominates Western philosophy and bioethics. In the course of our discussion, the diversity within Western culture becomes apparent. We discuss strategies for incorporating different perspectives into local and national allocation debates, clarify the reasons why a more encompassing approach to justice is necessary, and review the implications of our work for future research.

Beneficence↗
PubMed1992

An ethical framework for rationing health care.

This paper proposes an ethical framework for rationing publicly-financed health care. We begin by classifying alternative rationing criteria according to their ethical basis. We then examine the ethical arguments for four rationing criteria. These alternatives include rationing high technology services, non-basic services, services to patients who receive the least medical benefit, and services that are not equally available to all. We submit that a just health care system will not limit basic health care to persons unable to pay for it. Furthermore, justice in health care requires limiting publicly-financed non-basic health care, striving for equality in access to basic health care, and relying on medical benefit to ration non-basic health care.

Beneficence↗